Scoliosis

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Angie, a 4-year old, was noticed to have an unusual curvature of the back. Her parents were ignorant of it at first, attributing it to the immature development of her spine. However, they became bothered when they noticed that Angie’s curvature was already extremely turned to the right, prompting them to visit the nearby hospital. Angie was diagnosed with structural scoliosis.

Description


The term scoliosis is derived from the Greek word skolios (“twisted”) and refers to a sideward (right or left) curve in the spine.

  • Scoliosis is not a simple curve to one side but, in fact, is a more complex three-dimensional deformity that often develops in childhood.
  • The term infantile scoliosis is used specifically to describe scoliosis that occurs in children younger than 3 years.
  • Other terms for scoliosis also depend on the age of onset, such as juvenile scoliosis (4-9 years) and adolescent scoliosis (10-18 years).
  • Scoliosis is a lateral curvature of the spine, occurs in two forms: structural and functional (postural).

Types


There are two types of scoliosis:

  • Structural. Structural scoliosis involves rotated and malformed vertebrae.
  • Functional. Functional scoliosis, the more common type, can have several causes: poor posture, muscle spasm caused by trauma, or unequal length of legs.

Pathophysiology


Most cases of structural scoliosis are idiopathic; a few are caused by congenital deformities or infection.

  • Most of the curves in the spine develop during the first year of life, and strong correlation has been found between the nursing posture of the infant and development of the curve.
  • It is less common in the United States than in Europe, where babies are nursed in the supine position.
  • Infants have a natural tendency to turn toward the right side, and because of plasticity of the infant’s axial skeleton, this can lead to development of plagiocephaly, bat ear on the right side, and curvature of the spine toward the left side.

Statistics and Incidences


Many states require regular examination of students for scoliosis, beginning in the fifth or sixth grade.

  • Scoliosis is a rare condition, accounting for fewer than 1% of cases of idiopathic scoliosis in North America; in Europe, the rate is 4%.
  • Males account for 60% of the cases of early-onset scoliosis; 90% of the cases of early-onset scoliosis resolve spontaneously, but the other 10% progress to a severe and disabling condition.
  • Females constitute 90% of late-onset cases and need close monitoring to allow intervention at appropriate times.
  • Idiopathic scoliosis is seen in school-age children at 10 years of age and older.
  • Although mild curves occur as often in boys as in girls, idiopathic scoliosis requiring treatment occurs eight times more frequently in girls than in boys.

Causes


Although the exact cause of scoliosis is not known, hypotheses have been proposed on the basis of epidemiologic evidence.

  • Mechanical factors. One theory holds that the mechanical factors during intrauterine life are responsible for the higher incidence of plagiocephaly, developmental dysplasia of the hip, and scoliosis on the same side of the body.
  • Genetic and external factors. A second hypothesis suggests multifactorial causes, including predisposing genetic factors that are either facilitated or inhibited by external factors such as defective motor development or collagen disorders, joint laxity, and nursing posture of the infant.
  • Other factors. Other associations include older mothers from poorer families, breech presentation, and premature and male low-birth-weight babies.

Clinical Manifestations


Infantile scoliosis usually is detected during the first year of life either by the parents or by the pediatrician during routine examination of the infant.

  • Thoracic curve. Usually, a single long thoracic curve to the left is present; less often, a thoracic and lumbar double curve is noted.
  • Asymmetry. Observe asymmetry of the shoulders, shoulder blades, or hips.
  • Unequal distance of extremities. There is an unequal distance between the arms and waist.

Assessment and Diagnostic Findings


Diagnosis is made based on screening examination.

  • Radiography. Radiographs of the spine in infants are taken with the child held up by the arms; the severity of the scoliosis is established by calculating the rib-vertebral angle difference (RVAD) in the radiographs.
  • Computed tomography (CT). Computed tomography can be used to get a detailed picture of the scoliosis curve.
  • Magnetic resonance imaging (MRI). Magnetic resonance imaging is necessary in moderate-to-severe scoliosis because the reported frequency of neural axis abnormalities associated with scoliosis has been high (21-50% in some sources).

Medical Management


Treatment depends on many factors and is either surgical or nonsurgical.

Nonsurgical Management

Treatment is long-term and often lasts through the rest of the child’s growth cycle.

  • Electrical stimulation. Electrical stimulation may be used as an alternative to bracing for the child with a mild to moderate curvature; treatment occurs at night when the child is asleep, electrodes are applied to the skin;the leads are placed to stimulate muscles on the convex side of the curvature to contract as impulses are transmitted; this cause the spine to straighten.
  • Braces. The Boston brace or the TLSO brace is more commonly used to treat scoliosis; the brace should be worn constantly, except during bathing and swimming; its fit is monitored closely; it is worn over a T-shirt or undershirt to protect the skin.
A Chêneau brace achieving correction from 56° to 27° Cobb angle
  • Pedicle screw instrumentation. Because of advances in instrumentation, pedicle screw instrumentation can be performed for children with further growth potential; in these patients, a growing rod is used, which is associated with fewer complications than surgical fixation using L-rods.
  • Halo traction. When a child has  a severe spinal curvature or cervical instability, a form of traction known as halo traction may be used to reduce spinal curves and straighten the spine.

Surgical Management

The decision whether to operate on a patient with scoliosis depends on many factors.

  • Growing rods. Growing rods without fusion is preferable until combined posterior and anterior fusion can be done; growing-rod systems (eg, pediatric Isola instrumentation) may be utilized to prevent curve progression; extensions are needed every 6 months to keep pace with the child’s growth until the child has adequate trunk length, which is usually between the ages of 11 and 15 years.
  • Localizer cast. A localizer cast can hold the curve and prevent it from progressing further; the localizer cast is applied to the child’s trunk under general anesthesia, with traction to the head and neck via a sling across the mandible and the occiput and countertraction to the pelvis through another sling; the plaster jacket is applied around the trunk, with care taken to ensure that there is enough room for hip movements by stopping just below the level of the iliac wings; superiorly, the plaster goes around the axillae, leaving the arms and the shoulders free.
  • Pediatric Isola spine system. The Isola system consists of screws with washers that are applied from posterior to anterior, horizontal to the frontal plane of the vertebral body, and parallel to the apex of the curvature.; screws may be applied through the staples; rods are inserted to prevent progression of the curve, and the rods are extended every 6 months to keep pace with the child’s growth.

Nursing Management


Nurses play an important role in the management of a child with scoliosis, especially for the postoperative care.

Nursing Assessment

The child with scoliosis must be reassessed every 4 to 6 months.

  • Degree of curvature. Document the degree of curvature and related impairments.
  • Provide privacy. Provide privacy and protect the child’s modesty.
  • Assess emotional status. Be sensitive to the emotional state of the child; the family caregivers also may be upset but trying to hide it for the child’s sake.

Nursing Diagnoses

Based on the assessment data, the major nursing diagnoses are:

Nursing Care Planning and Goals

Main Article: 4 Scoliosis Nursing Care Plans

Major nursing care planning goals for the child with scoliosis include:

  • Minimizing the disruption of activities.
  • Preventing injury.
  • Maintaining skin integrity and self-image.
  • Complying with long-term care.

Nursing Interventions

Nursing interventions appropriate for the child with scoliosis are:

  • Promote mobility. Prescribed exercises must be practiced and performed as directed; this can help to minimize the risks of immobility and promote self-esteem.
  • Prevent injury. Evaluate the child’s environment after the brace has been applied and take precautions to prevent injury; help the child practice moving about safely; advise the family caregiver to contact school personnel to ensure that the child has comfortable, supportive seating at school.
  • Prevent skin irritation. Check the child regularly to confirm proper fit of brace; observe for any areas of rubbing, discomfort, or skin irritation and adjust the brace as necessary; skin under the pads should be massaged daily; and daily bathing is essential.
  • Promote positive body image. The child should be involved in all aspects of care planning; it is important for the child to have an opportunity to talk about his or her feelings; help the child select clothing that blends with current styles but is loose enough to hide the brace.
  • Promote compliance with therapy. The child must wear the brace for years until spinal growth is completed; during this period, the caregivers and the child need emotional support from healthcare personnel; to encourage compliance, teach them about possible complications of spinal instability and possible further deformity if correction is unsuccessful.

Evaluation

Goals are met as evidenced by:

  • Minimized disruption of activities.
  • Prevention of injury.
  • Maintained skin integrity and self-image.
  • Compliance with long-term care.

Documentation Guidelines

Documentation for a child with scoliosis includes:

  • Individual findings, including factors affecting, interactions, nature of social exchanges, specifics of individual behavior.
  • Cultural and religious beliefs, and expectations.
  • Plan of care.
  • Teaching plan.
  • Responses to interventions, teaching, and actions performed.
  • Attainment or progress toward desired outcome.

Practice Quiz: Scoliosis


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1. Veronica is a 14-year-old girl who wears a brace for structural scoliosis; which of the following statements indicate effective use of the brace?

A. “I sure am glad that I only have to wear this awful thing at night.”
B. “I’m really glad that I can take this thing off whenever I get tired.”
C. “I wonder if I can take the brace off when I go to the homecoming dance.”
D. “I’ll look forward to taking this thing off to take my bath every day.”

1. Answer: D. “I’ll look forward to taking this thing off to take my bath every day.”

  • Option D: The brace should be dropped for simply 1 hour of every 24-hour period for hygiene and skin care.
  • Option A: Wearing the brace at night would be true only following radiologic studies indicate the spine has bone marrow maturity and the adolescent has been weaned from off whenever 1 to 2 years.
  • Option B: Taking the brace off whenever tired indicates poor understanding of the brace.
  • Option C: Although physical appearance and social activities with peers are significant, the brace should not be excluded during these times.

2. Nurse Cheryl is assessing Fred, a 14-year-old boy who had scoliosis; besides checking neurologic status directly after Harrington rod instrumentation and spinal fusion, she should be regarded with which of the following factors?

A. Comfort level
B. Dietary tolerance
C. Physical therapy needs
D. Understanding of the procedure

2. Answer: A. Comfort level.

  • Option A: Instrumentation and spinal fusion cause considerable pain. Therefore, the adolescent needs vigorous pain management, which involves assessment, administration of pain medication, and evaluation of the response. In the immediate postoperative period, the child is conscious of sensation and surroundings.
  • Option B: Typically, shortly after surgery, the adolescent will not be taking anything by mouth.
  • Option C: Physical therapy is not an urgent postoperative goal at this time. However, it may be appropriate later on in the postoperative period.
  • Option D: Assessment and understanding of the procedure is a preoperative nursing responsibility.

3. A child with scoliosis has a spica cast applied. Which action specific to the spica cast should be taken?

A. Check the bowel sounds.
B. Assess the blood pressure.
C. Offer pain medication.
D. Check for swelling.

3. Answer: A. Check the bowel sounds.

  • Option A: A body cast or spica cast extends from the upper abdomen to the knees or below. Bowel sounds should be checked to ensure that the client is not experiencing a paralytic ileus.
  • Options B, C, and D: Checking the blood pressure is a treatment for any client, offering pain medication is not called for, and checking for swelling isn’t specific to the stem.

4. The clinic nurse asks a 13-year-old female to bend forward at the waist with arms hanging freely. Which of the following assessments is the nurse most likely conducting?

A. Spinal flexibility
B. Leg length disparity
C. Hypostatic blood pressure
D. Scoliosis

4. Answer: D. Scoliosis.

  • Option D: A check for scoliosis, a lateral deviation of the spine, is an important part of the routine adolescent exam. It is assessed by having the teen bend at the waist with arms dangling while observing for lateral curvature and uneven rib level. Scoliosis is more common in female adolescents.
  • Options A, B, C: A, B, and C are not part of the routine adolescent exam.

5. The nurse is caring for a 13-year-old following spinal fusion for scoliosis. Which of the following interventions is appropriate in the immediate post-operative period?

A. Raise the head of the bed at least 30 degrees.
B. Encourage ambulation within 24 hours.
C. Maintain in a flat position, logrolling as needed.
D. Encourage leg contraction and relaxation after 48 hours.

5. Answer: C. Maintain in a flat position, logrolling as needed.

  • Option C: The bed should remain flat for at least the first 24 hours to prevent injury. Logrolling is the best way to turn for the client while on bed rest.
  • Options A, B, D: These are not part of the immediate postoperative care period.

See Also


Related topics to this study guide:

Further Reading


Recommended resources and books for pediatric nursing:
  1. PedsNotes: Nurse's Clinical Pocket Guide (Nurse's Clinical Pocket Guides)
  2. Pediatric Nursing Made Incredibly Easy
  3. Wong's Essentials of Pediatric Nursing
  4. Pediatric Nursing: The Critical Components of Nursing Care

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